Guide with 180 Actual Exam Questions with 100% Verified
Correct Answers and Detailed Rationales | Rated A+!!!
Question 1
A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old. Which of
the following actions should the nurse take?
A. Tell the child they will feel discomfort during the catheter insertion.
B. Use a mummy restraint to hold the child during the catheter insertion.
C. Require the parents to leave the room during the procedure.
D. Apply a topical anesthetic 30 minutes prior to insertion.
Correct Answer: A
Rationale: The nurse should tell the child they will feel discomfort during the catheter
insertion. Honest communication builds trust and prepares the child for the procedure.
Using developmentally appropriate language, the nurse should explain what will happen
and what sensations the child might feel. Mummy restraints are used for infants, not 7-year-
olds. Parents should be allowed to stay to provide comfort and support.
Question 2
A nurse is caring for a client who has an arteriovenous fistula. Which of the following
findings should the nurse report?
A. Thrill upon palpation
B. Absence of a bruit
C. Distended blood vessels
D. Swishing sound upon auscultation
Correct Answer: B
Rationale: The absence of a bruit (whooshing sound) indicates decreased blood flow
through the fistula, which could mean the fistula is clotted or stenosed. This finding should
be reported immediately. A thrill (vibration upon palpation) and a swishing sound (bruit)
upon auscultation are normal findings indicating patency of the fistula.
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,Question 3
A nurse is providing discharge teaching for a client who has an implantable cardioverter
defibrillator (ICD). Which of the following statements demonstrates understanding of the
teaching?
A. "I will soak in the tub rather than showering."
B. "I will wear loose clothing around my ICD."
C. "I will stop using my microwave oven at home because of my ICD."
D. "I can hold my cellphone on the same side of my body as the ICD."
Correct Answer: B
Rationale: The client should wear loose clothing around the ICD to prevent friction and
irritation over the device site. The client should shower, not bathe in a tub. Microwave
ovens are safe to use. The client should hold the cellphone on the opposite side of the body
from the ICD.
Question 4
A nurse is caring for a client who is at 14 weeks gestation and reports feelings of
ambivalence about being pregnant. Which of the following responses should the nurse
make?
A. "Describe your feelings to me about being pregnant."
B. "You should discuss your feelings about being pregnant with your provider."
C. "Have you discussed these feelings with your partner?"
D. "When did you start having these feelings?"
Correct Answer: A
Rationale: The nurse should use an open-ended question to explore the client's feelings
about pregnancy. Ambivalence is common in the first trimester as the client adjusts to the
reality of pregnancy. The nurse should provide a nonjudgmental environment for the client
to express feelings.
Question 5
A nurse is planning care for a client who has a prescription for a bowel-training program
following a spinal cord injury. Which of the following actions should the nurse include in
the plan of care?
A. Encourage a maximum fluid intake of 1,500 mL per day.
B. Increase the amount of refined grains in the client's diet.
C. Provide the client with a cold drink prior to defecation.
D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
Correct Answer: D
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,Rationale: A rectal suppository should be administered 30 minutes prior to scheduled
defecation times to stimulate bowel evacuation. Fluid intake should be 2,000-3,000 mL/day.
A warm drink (not cold) stimulates peristalsis. Refined grains should be decreased, and
high-fiber foods increased.
Question 6
A nurse is caring for a client who is in active labor and requests pain management. Which
of the following actions should the nurse take?
A. Administer ondansetron.
B. Administer prescribed pain medication.
C. Encourage the client to use the birthing ball.
D. Prepare the client for epidural anesthesia.
Correct Answer: B
Rationale: The nurse should administer prescribed pain medication as ordered based on the
client's pain assessment and stage of labor. Pain management options include epidural
analgesia, systemic opioids, or non-pharmacological measures. The nurse should consider
the stage of labor and fetal status when selecting pain management options.
Question 7
A nurse in an emergency department is performing triage for multiple clients following a
disaster in the community. To which of the following types of injuries should the nurse
assign the highest priority?
A. Below-the-knee amputation
B. Fractured tibia
C. 95% full-thickness body burn
D. 10 cm (4 in) laceration to the forearm
Correct Answer: A
Rationale: In disaster triage, the highest priority (red tag) is given to clients who have life-
threatening injuries that are survivable. A below-the-knee amputation with active bleeding
requires immediate intervention. A 95% full-thickness body burn is expectant (black tag)
with a low survival rate. A fractured tibia and a 10 cm laceration are delayed (green/yellow
tag).
Question 8
A nurse manager is updating protocols for the use of belt restraints. Which of the following
guidelines should the nurse include?
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, A. Remove the client's restraint every 4 hr.
B. Document the client's condition every 15 min.
C. Attach the restraint to the bed's side rails.
D. Request a PRN restraint prescription for clients who are aggressive.
Correct Answer: B
Rationale: The nurse should document the client's condition every 15 minutes while in
restraints, including circulation, skin integrity, and mental status. Restraints should be
removed every 2 hours. Restraints should be attached to the bed frame, not side rails. PRN
prescriptions for restraints are not acceptable; a specific order is required.
Question 9
A nurse is teaching an in-service about nursing leadership. Which of the following
information should the nurse include about an effective leader?
A. Acts as an advocate for the nursing unit.
B. Avoids conflict at all costs.
C. Makes all decisions independently.
D. Delegates all tasks to others.
Correct Answer: A
Rationale: An effective leader acts as an advocate for the nursing unit, representing the
interests of staff and patients. Leadership involves advocating for resources, supporting
professional development, and fostering a positive work environment. Avoiding conflict is
not effective leadership; conflict should be addressed constructively. Independent decision-
making without input is autocratic, not effective. Delegating all tasks is inappropriate;
delegation should be appropriate and balanced.
Question 10
A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and
reports that she has been following her care. The nurse should identify which of the
following findings indicates a need to revise the client's plan of care.
A. Serum sodium 144 mEq/L
B. Serum potassium 4.2 mEq/L
C. HbA1c 10%
D. Random serum glucose 190 mg/dL
Correct Answer: C
Rationale: An HbA1c of 10% is above the expected reference range (normal <5.7%, target
for diabetes <7%) and indicates poor glycemic control. This finding indicates the current
plan of care is not effective and needs revision. A serum sodium of 144 mEq/L is within
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